Provider Demographics
NPI:1720536691
Name:WAGNER, JASON FREDRICK (APRN, LMHC, MCAP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:FREDRICK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:APRN, LMHC, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12521 SW 11TH CT
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-5585
Mailing Address - Country:US
Mailing Address - Phone:954-483-5455
Mailing Address - Fax:
Practice Address - Street 1:6075 BATHEY LN
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7536
Practice Address - Country:US
Practice Address - Phone:239-455-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8961101YA0400X, 101YM0800X, 101YA0400X
FLAPRN11004343363LP0808X
FLRN9378875163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health